Donald Trump has erased large swathes of data from government websites and replaced it with ideology for the worst of reasons; he seeks to reward the industries that give large amounts of money to Republican candidates.

‘White hat bias’ (WHB) [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends… WHB bias may be conjectured to be fuelled by feelings of righteous zeal, indignation toward certain aspects of industry, or other factors…

The new WHO recommendations on intrapartum care reflect righteous zeal instead of scientific evidence.

The title is the give away. There are 7 billion people whose health is under the purview of the WHO. As far as I can determine from searching their websites, in their entire 70 year history they have never demonstrated concern for the experience — positive or otherwise — of anyone receiving healthcare except women during childbirth.

Is the experience of the terminally ill irrelevant? Is the experience of pediatric patients of no concern? How about the experience of victims of natural disasters or refugees from wars? The WHO supervises care of all these group yet only demonstrates concern for the positive experience of a small subset, those eligible for midwifery care. That’s not a coincidence.

While the WHO has done exemplary work in the area of vaccines and other public health issues, it has unfortunately become a primary entity fanning the flames of moral panic around C-sections and breastfeeding.

A moral panic is a widespread fear, most often an irrational one, that someone or something is a threat to the values, safety, and interests of a community or society at large …

Listening to the WHO you might think that a high C-section rate and low breastfeeding rate threaten the health of world populations. You would be wrong. While low C-section rates have been shown repeatedly to lead to neonatal and maternal deaths, high C-section rates have no correlation with outcomes. For example, American avatars of C-section panic bewail our 32% C-section rate, but ignore the fact that Italy has a 42% C-section rate and lower rates of neonatal and maternal mortality.

Breastfeeding rates have absolutely no correlation with outcomes at all. The countries with the highest infant mortality rates have the highest breastfeeding rates and the countries with the lowest infant mortality rates have the lowest breastfeeding rates.

The ugly effort to generate moral panic around C-section rates seems to have originated with Dr. Marsden Wagner and has been fanned ever since by midwives in industrialized countries. It is the lie that will not die — his claim that the optimal C-section rate is between 5-15%.

Wagner, a pediatrician who served as the European Head of Maternal and Child Health for the WHO, without any evidence of any kind, declared the optimal rate by fiat in 1985. In 2009, the World Health Organization surreptitiously withdrew the target rate. Buried deep in its handbook Monitoring Emergency Obstetric Care, you can find this:

Although the WHO has recommended since 1985 that the rate not exceed 10-15 per cent, there is no empirical evidence for an optimum percentage … the optimum rate is unknown …

Childbirth is a normal physiological process that can be accomplished without complications for the majority of women and babies. However, studies show a substantial proportion of healthy pregnant women undergo at least one clinical intervention during labour and birth. They are also often subjected to needless and potentially harmful routine interventions.

Actually the key to a positive childbirth experience is a healthy baby and a healthy mother, neither of which is guaranteed.

The truth is that childbirth is a normal physiological process that naturally has an appalling rate of injury and death. In every time, place and culture it is a leading cause of death of young women and THE leading cause of death in the entire 18 years of childhood. Even today over 800 women and 14,000 babies (half stillborn) die EVERY DAY.

Many women want a natural birth and prefer to rely on their bodies to give birth to their baby without the aid of medical intervention,” says Ian Askew, WHO Director, Department of Reproductive Health and Research.

And many women, perhaps the majority of women, prefer to have pain relief, inductions, C-sections and all possible safety interventions.

In a future post I will address the specific recommendations, but for now I want to leave you with these questions:

Why is the WHO so concerned with patient experience in a world where so many mothers and babies die in childbirth each day?

Why is the WHO concerned only with the experience of pregnant women and ignores the experience of the largest consumers of healthcare, children and the elderly?

Why is the WHO generating moral panic about C-sections and interventions when there is no evidence that either is particularly harmful to patients?

Why do the WHO’s concerns map almost exactly to the concerns of midwives in industrialized countries?

Thank you so much for this article. I have thought exactly this for several years (since I had my first C-Section and encountered strong ideological bias against them from several people in my community; my midwife, my mother, several friends). I do not have a medical background and struggle to find the evidence to voice my frustration when people start ‘quoting’ WHO incorrectly, or without reading their full statements. I have read all their releases on this and find that their own statistical evidence does not support their ideological anti-C-section stance. I find your articles empowering as well as informative and greatly appreciate your work.

StephanieA

OT: my son had his 2 year check up today. He’s 34 inches tall and 30 lbs, which puts his BMI in the 86th percentile. That’s considered overweight, and now I’m worried and kind of sad. He’s always been stockier than his super skinny older brother, and I always thought he would just grow out of it since my husband and I are both thin. We realized that he is drinking way too much milk and his doctor recommended switching from whole to 2% since he’s over 2 now and cutting down the milk intake. Should I be worried? I just know that life is harder when you’re the chubby kid (also I really don’t think he looks fat at all, just solid).

fiftyfifty1

Don’t worry about this. Some kids are stockier. This was how my daughter grew. “Overweight” BMI until she slimmed out gradually during grade school. Cutting back a little on milk is fine, but don’t try to restrict him otherwise, e.g. don’t try to restrict calories or put him on a “health food” diet.

StephanieA

Oh I would never. We are not food purists, we don’t restrict any food groups. I cook most of our food but they also get junk food (this kid doesn’t even like sweets as much as his brother). I just wasn’t sure if it was something I should worry about.

BMI is increasingly being discarded as a reliable measure of obesity while the distribution and type of body fat is far more important as an indicator.

sdsures

Yep, but here in the UK, even though it’s supposed to be discarded, doctors STILL use BMI. Drives me nuts. :'( I am technically, by BMI standards, overweight, but I have anorexia…but the weight means I am not permitted to access eating disorders resources on the NHS. I will withhold food. :'(

Who?

My kids were born on high centiles for weight and length and got skinnier and more average (tending to the small/light side) by the time they started school, which makes sense when you see Huz and me. Which is my long way of saying, everyone can’t be average.

I think it’s very important to keep a sense of proportion. Both my daughters were n the 99th percentile for length and weight at birth. At age 7, the older was chubby, the younger slim. At the time the older was a very difficult eater while the younger ate everything. Today, at ages 36 and 34, the older is slender — and eats everything, while the younger needs to lose weight and is a very picky eater.

What a baby eats, and what he weighs(within reason, of course)does not mean that he will grow to be the same sort of adult.. Don’t be overly concerned.

sdsures

FWIW, both my husband and his brother are VERY tall and lanky, so much so that Husband was tested for suspected Marfan’s as a teenager. Thankfully, negative, as is his brother. But they do both possess the skeletal Marfan’s features, such as the fingers overlapping with the thumbs when you touch them together, the long fingers and toes, both are over 6ft tall and were large babies. They are also hypermobile and have velvety-soft skin due to a collagen defect.

A person can have Marfan’s without ever realizing it…until they drop dead of a heart attack and aortic dissection. No other cardiac history. Just BAM! Hits you like a train.

My biggest pet peeve with NCB including lactivism (today) is that they seem to confuse the relative importance of “needs” vs. “wants”.

I wanted to give birth with as short of a recovery time as possible to a healthy term baby who I could breastfeed easily.

I needed to have my son and I survive delivery and the neonatal period so I had a C-section at 26 weeks, pumped milk for him to reduce the risk of NEC and stopped pumping when I realized that the likelihood of being able to effectively breastfeed him was approaching 0% and he was out of danger of NEC.

Needs outweigh wants. That’s basic elementary school logic.

Montserrat Blanco

Same position here. I wanted a vaginal, no complications, no epidural birth at term, with exclusive breastfeeding.

I got a CS at 28 weeks, obviously with epidural, best NICU in the country, combo fed until 4 months old when my milk dried up.

I recovered very well from my CS and my son is perfectly healthy, thriving, and with a completely normal neurodevelopment. I could not be happier about the outcome and I do not regret the CS a bit. And I refuse to be sad about breastfeeding. We both are alive thanks to medical interventions. Thanks to A LOT of medical interventions AND formula.

sdsures

I was a 28-weeker, too! (Unknown reasons for preemie birth.) They told my mom I’d never walk or talk, and I’d be retarded. (Yes, I can use that word to refer to *myself* if I want to.)

I have moderate cerebral palsy and hydrocephalus, but am high-functioning, got a university degree and own my own business. No developmental delays.

*ex-preemie fistbump*

namaste

This. Put it this way: If Ryker Roque’s parents had recognized that rabies prophylaxis was the last thing he WANTED but the first thing he desperately NEEDED, he would Be very much alive.

sdsures

No child on earth wants to get a shot. EVER! But do parents then always bend to the whim of a screaming kid? No way!

fiftyfifty1

OT: I just read Serena Williams’ statement on CNN and I am dumbfounded. She praises her “incredible medical team of doctors and nurses…[…]… they knew exactly how to handle this complicated turn of events.” (This praise for the team that delayed and branded her crazy when she alerted them to her PE!) She then goes on to call for more midwives, breastfeeding and skin-to-skin for the developing world. She does call for access to clean water, meds and more facilities too, and that part seems right on. But no mention of specialists, ORs, CS capacity, you know the stuff that really saves lives.

Tigger_the_Wing

Wow. Sounds as if she’s self-gaslighting!

MaineJen

Or she’s been thoroughly debriefed by a couple of midwives. I’d love to hear how more midwives, breastfeeding or skin to skin could have solved her PE.

Sarah

Don’t, you know someone will parachute in and give us a lengthy explanation of just that.

ukay

That‘s probably it. For some reason it has become conventional wisdom that breastfeeding+midwife+ other stone age practices=good outcome guaranteed. Despite of all the evidence to the contrary.

sdsures

“Debriefing is a process of:

receiving an explanation,
receiving information and situation-based reminders of context,
reporting of measures of performance, and/or opportunities to further investigate the results of a study, investigation, or assessment of performance after participation in an immersive activity is complete.”

Somehow, I don’t think “debriefing” is what midwives did in regards to Ms Williams. :-/ It doesn’t mean you editorialize an experience to make it seem rosier.

mjd3

She’s probably just listing some talking points prepared for her by Unicef (in fact the whole thing was likely ghostwritten). I thought as a whole the article was pretty ok as far as international health goes. But yeah, it does seem to be deliberately not mentioning the need for CS, and even worse, contains no real analysis of what black women *in the US* are lacking. My guess is that Unicef reached out to her PR agents and wrote this canned op-ed for her.

I am probably in the minority, but the only subject that I’d take advice from Serena Williams is how to play tennis. Having given birth doe not make one an expert on birth. While I can give informed adviceon birth, I hope no one ever asks me anything about tennis.

sdsures

Right?? She did have a bit part in an early season of “Law and Order: Special Victims Unit” that I liked.

Who?

The Guardian seem to be reporting it in a more nuanced way, linking to the CNN piece:

Erm, does the developing world not have enough skin to skin contact already? Why in hell is a rich, superstar tennis player advising on what should be done in a dirt-poor developing country to help moms who can’t afford bread?

mjd3

“Many women want a natural birth and prefer to rely on their bodies to give birth to their baby without the aid of medical intervention.”

What the actual hell? NO. Mothers want healthy babies and healthy selves. If given the choice between an uncomplicated vaginal birth and a c-section probably most will chose the former. But the proportion of women who truly want to forgo the “aid of medical intervention” is exceedingly small, likely limited to the hardest core Unattended Birthers. Other than that, women are choosing all manner of intervention, from getting their glucose checked, to sonagrams, to sterile technique in L&D. And certainly all women prefer to have the option to more intensive medical interventions as needed to save their or their babies lives.

I haven’t seen the movie – but reading the follow-up interviews was fascinating.

The Namibian family made their carefully thought out choice on what would be a major financial savings for their family.

The Mongolian family point-blank mentioned how much safer they felt their child was with the filming crew keeping an eye on the baby while the adults worked outside.

The US family, on the other hand, is attempting to argue that their daughter wasn’t “really” in the NICU for three days for breathing difficulties because she was a term baby not a 27-week preemie.

The US family also seemed to miss the part of the movie where the Mongolian baby was close enough to cattle that the other three families were frightened after seeing the video.

I know which family gets my vote for “Most Out of Touch With Reality”.

sdsures

I’m not sure if watching this show is going to be fascinating or infuriating.

Perhaps a better title for the show would be “Who Wants to Be Most Out of Touch With Reality?” (Like “Who Wants to Be a Millionaire?” 😛 )

Sarah

I actually think the WHO should be concerned with patient experience, even in a world where perinatal and maternal mortality are still problems. That in itself isn’t a bad thing at all: we should be aiming for plenty more than live mother and live baby as an outcome. That’s a bare minimum. The things that happened to me during childbirth still matter, even though nobody died. The problem is the bullshitting and inaccuracy, not the desire to consider patient experience in itself.

Roadstergal

“Many women want a natural birth and prefer to rely on their bodies to give birth to their baby without the aid of medical intervention,” says Ian Askew, WHO Director, Department of Reproductive Health and Research.”

Many people want naturally good sight and prefer to rely on their eyes to see without the aid of medical intervention.

Many kids want natural pancreatic function and prefer to rely on their bodies to regulate their insulin without the aid of medical intervention.

Many people want natural kidney function and prefer to rely on their bodies to filter their waste without the aid of medical intervention.

I expect to be given a prominent position in the WHO for my daring statement of these undeniable facts.

attitude devant

I really wonder about WHO. I imagine there are a bunch of midwives showing up to ALL the meetings and writing policy briefs because obstetricians are too damn busy actually caring for patients to sit around and philosophize about birth.

We just had a patient come in with the same thing that killed the midwife in Dr. Amy’s February 13th column. Not even in labor. Perfectly healthy and boom! Nothing for it but an emergency c/s under general anesthesia. I am sick of being told that my ‘interventions’ cause complications when every time I turn around I have to struggle mightily to keep someone from flat-out dying. As I move toward retirement, I have thought about volunteering in an obstetrical hospital in India or Africa, and I’m terrified to do it, because technology (my OR, my monitors, my drugs, my blood bank) are what save my patients.

Maybe I should be ‘holding the space’ better?

fiftyfifty1

Would you have any access to anesthesia. Would you be able to do CS at all?

attitude devant

Some places, yes.

momofone

Have you considered knitting in your patients’ rooms? I’ve heard it works wonders for midwives. (Not so sure about the patients, but you can’t have it all, right?)

Empress of the Iguana People

Does admiring patients’ knitting count? If so, my ob must be doing alright. He quite liked my crazy purple socks that I was working on while waiting for him.

Lilly de Lure

My surgical team were great at that too – they loved (or at least were very complimentary about) the little hat (oh the horrors!) that I’d knitted for my son and were delighted to use it rather than the standard hospital hats for him after his initial exam.

sdsures

NICUs almost always are in need of preemie sized hats, and possibly preemie clothes, oh and special octopus toys for preemies to grab onto. Just make sure to follow the guidelines set forth by the hospital when choosing the type of yarn you use.

Non-synthetic (ie natural like cotton or wool, though not sure about wool) is preferred. 100% wool might be too abrasive for the very delicate skin of micropreemies. They lack surfactant, so their skin looks brittle and tears easily. When I was a 28-weeker, synthetic surfactant wasn’t yet available. Now it is.

Preemie skin toughens up really quickly after a few days – much to my surprise. I think the bigger problem with 100% wool would be shrinkage since NICUs send anything that will be in contact with a preemie through high heat wash and dry to sanitize them.

*giggles* My doctors always ask about my knitting. I’ve given knitted stuff to them as presents!

sdsures

*chuckles*

Amazed

Maybe you should “have trust in birth and your speshul skillz”. That’s what works for midwives… when mom is healthy, baby is healthy, and labour is progressing normally…

sdsures

MSF does great work in developing countries, but man, they must have balls of STEEL! I couldn’t be as brave as they are to work in such conditions.

Empress of the Iguana People

God, that man is such a trigger for me. And I’m already having a tough couple days in my head.

attitude devant

You do realize he’s dead and will soon be forgotten, right? I must say, though, the thing that always pissed me off most was his soi-disant title of perinatologist. Ummm, no dude. What are you, the White Knight, claiming words mean what you want them to? That word has an actual accepted definition, and you ain’t it.

Empress of the Iguana People

He may be soon forgotten but he’s our president for now. blergh

MaineJen

I think you are talking about two different men. Both equally despicable.

attitude devant

Oh Empress! I was talking about Marsden Wagner! I completely misunderstood you!

Empress of the Iguana People

It’s okay. Old Marsden probably is a problem for someone. Easier for me to ignore him, tho.

Amy Tuteur, MD

Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, Push Back: Guilt in the Age of Natural Parenting (HarperCollins) was published in 2016. She can be reached at DrAmy5 at aol dot com...
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